Cardiovascular

Exclusion of Arteriovenous Shunts in Intracerebral Hemorrhage Using MRI Arterial Spin Labeling: A Prospective Multicenter Study.

Beaufort Q, Agripnidis T, et al. • Neurology • 2026

PubMed 42956389 DOI 10.1212/WNL.0000000000218705
TL;DR

In an unselected, low-prevalence adult ICH population, ASL demonstrated excellent diagnostic accuracy and a near-perfect NPV, indicating that a negative ASL reliably excludes AVS.

Key Findings

Results

Arteriovenous shunts were confirmed in 8.7% of the 277 included adults with nontraumatic ICH, almost all of them AVMs.

  • Of 537 enrolled patients in the OPTICH cohort, 277 met inclusion criteria (median age 71 years [IQR 60-80]; 163 [58.8%] men).
  • An AVS was confirmed in 24 patients (8.7%): 23 AVMs and 1 dAVF.
  • All AVSs were confirmed by DSA.
  • Patients were recruited consecutively across 3 French tertiary hospitals (October 2022-October 2025).
Results

ASL showed high sensitivity and specificity for detecting AVSs in acute ICH.

  • Sensitivity was 95.8% (95% CI 79.8-99.3).
  • Specificity was 94.5% (95% CI 90.9-96.7).
  • Overall accuracy was 94.6% (95% CI 91.3-96.7).
  • ASL was rated positive when focal hyperperfusion was seen adjacent to the hematoma; the reference standard was the final adjudicated etiologic diagnosis.
Results

A negative ASL had a near-perfect NPV, while PPV was modest.

  • NPV was 99.6% (95% CI 98.1-99.9).
  • PPV was 62.2% (95% CI 46.1-75.9).
  • The authors conclude that a negative ASL reliably excludes AVS in this low-prevalence population.
Results

Interobserver agreement for ASL rating was excellent.

  • Cohen's kappa was 0.88.
  • ASL maps were independently evaluated by 2 blinded neuroradiologists.
Results

ASL detected all AVSs seen on initial DSA and flagged 3 AVSs that were occult on initial DSA.

  • All AVSs identified on initial DSA were detected by ASL.
  • 3 ASL-positive AVSs were occult on initial DSA.
  • All AVSs were ultimately confirmed by DSA.
Conclusions

The authors propose ASL as a noninvasive gatekeeper to DSA within standard MRI protocols for ICH etiologic workup, pending external validation.

  • DSA is invasive, uses ionizing radiation, carries a non-negligible complication risk, and is not readily available in many centers.
  • Main limitations were selective DSA use, few non-AVM shunts (1 dAVF), and modest scanner heterogeneity.
  • The authors state that external validation is needed.

What This Means

After a bleed inside the brain, doctors need to find out whether an abnormal tangle or shortcut between arteries and veins (an arteriovenous shunt) caused it, because these can bleed again and need specific treatment. The standard test, catheter angiography (DSA), is invasive, uses radiation, carries some risk, and is not available everywhere. This study tested whether a noninvasive MRI technique called arterial spin labeling (ASL), which maps blood flow without contrast injection, could detect these shunts. The study followed 277 adults with brain hemorrhage at 3 French hospitals. Twenty-four (8.7%) had a confirmed shunt, nearly all of them arteriovenous malformations. ASL correctly identified 95.8% of those with a shunt and correctly cleared 94.5% of those without. When ASL was negative, a shunt was almost certainly absent (99.6%). When ASL was positive, a shunt was confirmed in about 62% of cases, so positive scans still need follow-up angiography. Two radiologists reading the scans independently agreed closely, and ASL flagged 3 shunts that the first angiogram had missed. This research suggests that ASL added to a standard MRI could help rule out shunts and spare many patients an invasive angiogram, with angiography reserved for those with a positive ASL. The authors note limitations: not all patients had angiography, only one non-malformation shunt (a dural fistula) was found, and scanners varied somewhat. They say the findings need confirmation in other centers before routine adoption.

Have a question about this study?

Presence or severity of Hashimoto's thyroiditis does not influence basal calcitonin levels: observations from CROHT biobank.
Journal of endocrinological investigation • 2022

HT patients of all disease stages preserve Ct production as healthy individuals and there is no need for Ct measurements...
Approach to the Patient: Safety of Growth Hormone Replacement in Children and Adolescents.
The Journal of clinical endocrinology and metabolism • 2022

rhGH therapy has been used for more than 3 decades and data are largely reassuring, yet we still have much to learn abou...
Extended Absorption of Liothyronine from Poly-Zinc-Liothyronine: Results from a Phase 1, Double-Blind, Randomized, and Controlled Study in Humans.
Thyroid : official journal of the American Thyroid Association • 2022

PZL possesses the necessary properties to achieve a much improved T3 pharmacokinetic profile, with ~30% lower Cmax that...
Lipoprotein subtypes after testosterone therapy in transmasculine adolescents.
Journal of clinical lipidology • 2022

Testosterone appears to be a major contributor to differences in lipoprotein profiles, a surrogate for cardiovascular di...
Long-term testosterone undecanoate treatment in the elderly testosterone deficient male: An observational cohort study.
Andrology • 2022

Long-acting testosterone undecanoate treatment in elderly testosterone-deficient patients required more frequent dose ad...
Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism.
Clinical endocrinology • 2022

The Society for Endocrinology commissioned a multidisciplinary guideline to provide all care providers with a comprehens...

Citation

Beaufort Q, Agripnidis T, Amar V, Pandaure B, Bretonniere A, Cottier J, et al.. (2026). Exclusion of Arteriovenous Shunts in Intracerebral Hemorrhage Using MRI Arterial Spin Labeling: A Prospective Multicenter Study.. Neurology. https://doi.org/10.1212/WNL.0000000000218705